Housemanship programme in Malaysia:

Availability of positions and quality of training

Lim Chee Han, PhD

Press ConferencePenang Institute in KL, Uppercase

21 July 2017

Outline

1. Introduction

2. Study Objectives & Methodology

3. Report discussion points: Unrealistic target number of medical doctors required in Malaysia

Sharp surge in the numbers of medical students entering the workforce

Proliferation of recognized medical institutions over the years

The turnover of Housemanship positions

The capacity of MOH to accommodate more housemen

Housemanship extension and training quality

4. Policy Recommendations

Introduction

Journey of an aspiring medical doctor

• Many Asian parents might have unrealistically glamorous view of the

medical profession and dream that their child follows suit. This kind

of interest might be sparkled by popular culture such as Grey’s Anatomy

(US) and Healing Hands (HK).

• Entry into medical field used to be very competitive – limited positions

of medical courses in the public universities or very costly overseas

education.

• Today, quite a number of medical programmes offered by local private

institutions, typically cost around RM60,000-RM100,000 per year.

• Though exorbitant costs and considerable duration length (5 years),

medical programmes are still in high demand.

Journey of an aspiring medical doctor

Medical

Student

Entry Enrolment (5 Years) Graduate (MBBS or MD)

HE institutions• Local Public• Local Private• Foreign

HOUSEMAN• Provisionally Registered• 2 years posting programme:- 5 core disciplines (4 months each):Internal Medicine, Paediatrics, Surgery, Obstetrics and Gynaecology, & Orthopaedics

- 4 elective disciplines (choose one):Emergency Medicine, Anaesthesiology, Primary Care & Psychiatry

Medical

Officer

(MO)

• Fully Registered on Medical Register (MMC)• Compulsory service in public sector for a minimum of 2 years• Annual Practicing Certificate then issued

Specialist

After more than 4-5 years.Voluntary registered in

National Specialist Register

Adopted from

SCHOMOS

Guidebook 2016,

Malaysian Medical

Association

Journey from Medical Student to Houseman

Issues at stake

The issues

• Today, many training hospitals cannot cope with the rising demand for

housemanship positions.

• ‘There are just too many doctors and too many medical institutions

flooding the market’ – former MMA president Datuk Dr N.K.S.

Tharmaseelan (2013)

• Since 2000, all public and private medical schools in Malaysia have

been accredited and recognised by the Malaysian Medical Council

(MMC).

• The trend of rapid proliferation of medical schools in Malaysia

probably cause the available pool of medical teachers to be spread very

thin, while lowering the entry requirements for medical programmes as

a way of wooing prospective students, in the long run, would have

severe negative impacts on the healthcare service standard in Malaysia.

The issues

• An oversupply of medical graduates will cause a systemic shock

to the MOH training capacity, especially when poor performers

extend their stay and ‘clog up’ the system. That causes

increasingly longer wait for the medical graduates to secure a

housemanship position.

• The number of experienced specialists who are willing and able

to supervise the house officers will determine the quality of the

housemanship programme. However, specialists from certain

disciplines might not be enough, resulted in large mentor-mentee

group.

Study Objectives

1. The supply and demand of medical graduates in Malaysia and the impact of

current policies by MOH and MOHE on the numbers of medical graduates

produced each year, the institutions involved in provision of medical courses, and

quality of such medical training

In this study, we investigate…

Incoming: Outgoing:

CAPACITY of MOH

2. The capacity of public hospitals to train house officers, in terms of physical

and human resources, i.e. the no. of training hospitals and specialist trainers.

Mentor specialists

3.The quality of housemanship training, the performance of

housemen and their ability to cope with various situations

Methodology

Medical Register (MMC)

Medical Register (MMC)

24,500 doctors’ details were analysed

for housemen who entered the

workforce from 2008 to 2014

Finding 1:Unrealistic target number of

medical doctors required in

Malaysia

Number of Doctors in Malaysia

15,619 16,14617,442

18,191

18,24620,105

21,93723,738

25,102

30,536

32,979

36,60738,718

46,916

45,565

46,491

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

50,000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Source: Health Indicators, Ministry of Health

Doctor: Population ratio (1:x) --> 758 633 661 656

Number of Doctors in Malaysia

15,619 16,14617,442

18,191

18,24620,105

21,93723,738

25,102

30,536

32,979

36,60738,718

46,916

45,565

46,491

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

50,000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Source: Health Indicators, Ministry of Health

Population projection in 2020 = 33.8 millionTo achieve the 11MP target at 1:400 ratio,Malaysia needs to have 84,456 doctors, ie 37,965 more.

Doctor: Population ratio (1:x) --> 758 633 661 656

Year

No. of

medical

graduates (1)

No. of

housemanship

positions filled up

(2)

Supply gap

housemanship

positions:

Supply (2) – Demand

(1)

No. of

housemanship

positions

released locally

(3)

Difference in

the vacated

and demand

for positions:

(3) - (1)

2000 996 829 -167

2001 1029 780 -249 1009 -20

2002 1104 997 -107 1011 -93

2003 1083 959 -124 583 -500

2004 1126 1036 -90 874 -252

2005 1112 1049 -63 1060 -52

2006 1122 1059 -63 1703 581

2007 1534 1298 -236 1622 88

2008 2530 2326 -204 1787 -743

2009 3147 3058 -89 364 -2783

2010 3256 3252 -4 2326 -930

2011 3708 3565 -143 2923 -785

2012 4094 3743 -351 3086 -1008

2013 4472 4991 519 3374 -1098

2014 4740 3860 -880 3602 -1138

2015 5146 4121 -1025

Source: MMC Annual Report, MOH Human Resources Division and own calculations

Supply gap and clearance of

housemanship positions

Finding 2:Sharp surge in the numbers of

medical students entering the

workforce

No. of House-Officers

by Local Public vs Private medical graduate origin

Source: Human Resources Division, Ministry of Health

496

658 683 680 659609

740808

875

1012

10881151

1147

1245

43

172 167227

286

384 364

641

851 852877

1029

1441

1125

0

200

400

600

800

1000

1200

1400

1600

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Local Public Universities Local Private Universities/Colleges

2.5x

26x

No. of House-Officers

by Local vs Overseas medical graduate origin

Source: Human Resources Division, Ministry of Health

539

830 850 907 945 9931104

1449

17261864

1965

2180

2588

2370

241 167 109 129 104 66194

877

1332 1388

1600 1563

2403

1490

0

400

800

1200

1600

2000

2400

2800

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

TOTAL Local Graduate TOTAL Overseas Graduate

6x

Source: Human Resources Division, Ministry of Health

No. University 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014Local Public Universities

1 University of Malaya (UM) 137 175 182 175 149 144 150 141 150 159 182 188 198 197

2

National University of Malaysia (UKM) 131 160 162 160 160 142 185 203 173 223 219 259 220 208

3

University of Science Malaysia (USM) 150 185 201 181 147 159 151 179 191 186 180 193 193 205

4

University of Malaysia Sarawak (UNIMAS) 38 38 22 33 47 13 76 68 53 79 64 74 39 92

5

University Putra Malaysia (UPM) 40 54 61 72 82 69 90 81 123 101 131 111 143 99

6

International Islamic University of Malaysia (IIUM) 46 55 59 74 82 88 88 95 105 121 108 96 128 -

7

University of Malaysia Sabah (UMS) - - - - - - - 29 36 68 75 70 80 81

8

University of Technology Mara (UiTM) - - - - - - - 19 54 91 116 148 178 182

9

Islamic Science University of Malaysia (USIM) - - - - - - - - - - - - - 53

Sub-total 496 658 683 680 659 609 740 808 875 1012 1088 1151 1147 1245

No. of House-Officers

by Local Public medical graduate origin

Source: Human Resources Division, Ministry of Health

No. University 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014Local Private Universities/Colleges

1 Penang Medical College (PMC) 43 59 23 31 19 132 64 105 97 131 100 97 150 115

2International Medical University (IMU) - 90 76 72 109 64 117 156 148 140 118 231 183 136

3Royal College of Medicine Perak (RCMP) - 23 - - 4 10 53 57 82 63 23 19 136 119

4Malacca-Manipal Medical College (MMMC) - - 68 124 154 178 130 222 405 271 254 249 258 117

5Asian Institute of Medicine and Technology (AIMST) - - - - - - - 101 119 134 113 108 205 14

6Alliance College of Medical Science (AUCMS) - - - - - - - - - 52 30 69 58 89

7 Monash University (SUNWAY) - - - - - - - - - 29 27 10 71 76

8University College Sedaya International (UCSI) - - - - - - - - - 32 43 41 50 32

9Cyberjaya University College of Medical Sciences (CUCMS) - - - - - - - - - - 140 133 126 143

10Management & Science University (MSU) - - - - - - - - - - 29 38 62 186

11 MAHSA University - - - - - - - - - - - 34 142 98Sub-total 43 172 167 227 286 384 364 641 851 852 877 1029 1441 1125

No. of House-Officers

by Local Private medical graduate origin

In view of the increasing number of housemen, the MOHE had in 2011 placed a moratorium

on the number of new institutions that can offer medical programmes since 2011.

"The rational behind the moratorium is to manage the number of students entering medical

programmes locally and to address concerns such as a surplus of houseman (waiting time).”

Director-General of MoHE Datuk Dr Asma Ismail, 17 March 2016

15.1% 15.8% 16.7%11.3% 13.2%

11.6% 10.3%

20.8% 21.1% 19.8% 24.3%

39.8%

51.8%

59.1%56.7% 58.1%

58.4% 49.3%

25.3%

16.7%17.7%

77.4% 79.2% 78.2%

73.6%

65.1%68.5%

76.8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

2008 2009 2010 2011 2012 2013 2014

Australia+UK+Ireland Indonesia+Egypt

Russia+Ukraine Russia+Ukraine+Indonesia+Egypt

Foreign trained medical graduates

by selected country

Finding 3:Proliferation of recognised medical

institutions over the years

Top 10 origin countries

with most number of

medical institutions recognised

Rank No. Country No. of Institutions Recognised

1 UNITED STATES OF AMERICA 89

2 INDIA 52

3 UNITED KINGDOM 33

4 MALAYSIA 29

5 CANADA 14

6 AUSTRALIA 13

7 INDONESIA 13

8 JAPAN 10

9 TAIWAN 8

10 ARAB REPUBLIC OF EGYPT 7

PAKISTAN 7

Source: Malaysian Medical Council – Second Schedule of Medical Act , updated 2017 Jan

Proliferation of Recognised Medical Institutions

Pre-1980 1980-89 1990-99 2000-09 2010-2016

Addition 219 20 41 38 20

Cumulative 219 239 280 318 338

219

20

41 38

20

0

50

100

150

200

250

300

350

0

50

100

150

200

250

Cu

mu

lati

ve n

o. o

f In

stit

uti

on

s

No

. of

Ad

dit

ion

Number of Recognised Medical Institutions

Addition Cumulative* 1 institution with no date

Source: Malaysian Medical Council and own calculation

Proliferation of Recognised Medical Institutions

Pre-1980 1980-89 1990-99 2000-09 2010-2016

Addition 219 20 41 38 20

Cumulative 219 239 280 318 338

219

20

41 38

20

0

50

100

150

200

250

300

350

0

50

100

150

200

250

Cu

mu

lati

ve n

o. o

f In

stit

uti

on

s

No

. of

Ad

dit

ion

Number of Recognised Medical Institutions

Addition Cumulative* 1 institution with no date

Source: Malaysian Medical Council and own calculation

• I.M. Sechenov First Moscow State Medical University• Nizhny Novgorod State Medical Academy• Volgograd State Medical Academy• Kursk State Medical University

• Crimea State Medical University (Ukraine, 2001)

(Russia, 2001)

Pre-1980 1980-89 1990-99 2000-09 2010-2016

Addition 2 1 0 11 15

Cumulative 2 3 3 14 29

21

0

11

15

0

5

10

15

20

25

30

35

0

2

4

6

8

10

12

14

16

Cu

mu

lati

ve n

o. o

f In

stit

uti

on

s

No

. of

Ad

dit

ion

Addition Cumulative

Source: Malaysian Medical Council and own calculation

No. of recognised Medical Institutions

from Malaysia only

• Rapid addition of accredited local institutions since 2000.• No. of accredited local private institutions have shot up from 0 to 18

Finding 4:The turnover of housemanship

positions

1853

2548 2519

26722744

2687

2094

77.4%84.6%

81.2%76.9% 72.6%

65.2%58.8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

1800

1900

2000

2100

2200

2300

2400

2500

2600

2700

2800

2008 2009 2010 2011 2012 2013 2014

Nu

mb

er

Year of Provisional Registration

Source: MMC Medical Register, and own calculation

No. of housemen obtained

full registration within 24 months

• More housemen needed extension of training ( < 60% finish in time for year batch 2014)

368430

574

795

1016

1412 1441

0

200

400

600

800

1000

1200

1400

1600

2008 2009 2010 2011 2012 2013 2014

No

. of

Ho

use

man

Year of provisional registration

>24m

>28m

>32m

>36m

Source: MMC Medical Register, and own calculation

“Overdue” Housemanship

• Increasing number of housemen who could not finish within 24 months

Source: MMC Medical Register, and own calculation

Medical Education background of housemen

dropped out or failed to obtain full registration

27.1%34.6%

21.9% 18.1% 22.5% 23.2%17.0%

27.1%20.2%

21.1% 22.8% 17.9%23.2%

21.2%

44.7% 45.2%57.0% 59.1% 59.6% 53.5%

61.9%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2008 2009 2010 2011 2012 2013 2014

Local public Local private Foreign

• Among housemen who dropped-out, ~60% graduated from overseas

Where were the overseas dropouts

received their education?

Medical Institution(s) 2008 2009 2010 2011 2012* 2013* 2014*

RUSSIA+UKRAINE+INDONESIA

R+U+ID33 35 53 80 95 76 246

86.8% 74.5% 72.6% 79.2% 66.4% 47.8% 44.3%

RUSSIA+INDONESIA+INDIA+EGPYT

R+ID+IN+E21 22 30 57 109 130 463

55.3% 46.8% 41.1% 56.4% 76.2% 81.8% 83.4%

THE REST OF REGIONS

The REST (non R+U+ID+IN+E)5 10 19 21 34 28 85

13.2% 21.3% 26.0% 20.8% 23.8% 17.6% 15.3%

TOTAL FOREIGN INSTITUTIONS

Total FOREIGN 38 47 73 101 143 159 555

Finding 5:The capacity of MOH to

accommodate more housemen

Efficiency for 2016 (or up till March ’17?) =

48.6%

Housemanship Training Hospitals

(2017)State No.

Perlis 1

Kedah 3

Penang 2

Perak 4

Selangor 6

KL & Putrajaya 4

Negeri Sembilan 2

Melaka 1

Johor 6

Pahang 2

Terengganu 2

Kelantan 4

Pre-2011

2011-2015

Hospital

Angkatan

Tentera

Malaysia (3)

Source: Medical Development Division, Ministry of Health

Housemanship Training Hospitals

(2017)

State No.

Sabah 3

Sarawak 4

Pre-2011

2011-2015

Nationwide TOTAL =

44

Source: Medical Development Division, Ministry of Health

Discipline Area

(Core/Elective)

No. of MOH

Specialists

1 Internal Medicine (General) 668

2 General Paediatrics 391

3 General Surgery 248

4 Obsterics and Gynaecology (O&G) 232

5 Orthopaedic Surgery 224

6 Emergency Medicine 139

7 Anaesthesiology and Critical Care 397

8 Family Medicine 146

9 Psychiatry 108

Assumed no. of

specialist(s) per core

discipline per

hospital

No. of

housemanship

training hospitals

Possible no. of

housemanship

trainers/mentors

No. of housemen

allocated per core

discipline (Assume equal

distribution)

Ratio of

Specialist:

Housemen

1 44 44 1806 1:41

2 44 88 1806 1:21

3 44 132 1806 1:14

4 44 176 1806 1:10

5 44 220 1806 1:8.2

6 44 264 1806 1:6.8

7 44 308 1806 1:5.9

8 44 352 1806 1:5.1

9 44 396 1806 1:4.6

Source: National Specialist Register (Feb 2017)

Specialists/Trainers

Finding 6:Housemanship extension and

training quality

Consequences of

poor planning & management

Consequences of

poor planning & management

1/3 housemen were extended yearly!

~55% = Incompetent

~45% = Disciplinary issues

48.4%

Consequences of

poor planning & management

Source: Institute of Health Management Malaysia, MOH

Policy recommendations• MOH should train significantly more specialists and retain them in the public sector

• MOH should revise the structure of the housemanship programme to be more

effective in supporting or incentivising specialist trainers

• An independent tribunal or ombudsman should be established for housemen to

address their grievances should they feel that they have been abused or unfairly

treated – Recommend: SCHOMOS

• MOH should explore the possibility of forging partnerships with private hospitals

to utilise their expertise and resources to train more housemen, through voluntary

schemes. Attractive incentives should be given and the cost burden of training

should be shared with willing participating hospitals and their consultants.

• Local private and overseas medical education institutions must be more tightly

regulated

• There should not be a further increase in the number of local private and public

universities offering medical programmes until the housemanship issue is resolved

• There should be a strictly enforced cap on the yearly medical student intake for

existing local programmes.

Acknowledgement

Dr. Ong Kian Ming (General Manager)Dr. Ooi Kee Beng (Executive Director)Dr. Sem Xiao Hui

Thanks to Penang Institute (Think Tank Turns Twenty)

&

The KL office team:

Special Thanks to

Dr. Lyana KhairuddinEsther Sinirisan Chong Shiaw YeeLim Su Lin

Thank you!